Give someone authorisation

Authorise someone to arrange your health care matters

Note: on the form, we ask the both of you for an official signature. Without them, we can unfortunately not accept authorisation (power of attorney).

My details

 
 
 
 
optional
 
   
 
Find your BSN on your driving license or passport
 
Find it on your insurance card or policy document
 

I authorise

 
 
 
 
optional
 
   
 
Fill in only if you are insured at Zilveren Kruis


 

Authorisation period

Please note! The authorisation is valid up to 5 years.

 
 

Signature

 

Please note! This form is only valid with both signatures. Yours and the person you authorise. Scan or take a digital picture of both signatures. Add that as an attachment. You can only upload .pdf, .jpg, of .png files.

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